Every finding on record at First Choice Hospice Inc

Upon patient record review, 2 of 15 (Patient #4,#14) did not have evidence in the patient record that the hospice has developed an individualized written plan of care for each patient. The plan of care must reflect patient/family goals and interventions based on the problems identified in the initial, comprehensive, and updated comprehensive assessments. The plan of care must include all services necessary for the palliation and management of the terminal illness and related conditions. Patient 4:The medical record includes an order dated 10/21/22 for oxygen 3 liters per minute via nasal cannula as needed for dyspnea. There is no evidence that the plan of care includes problems, goals or interventions for the use of oxygen. Patient 14:The medical record contains an order dated 11/4/22 for 1 bottle of Ensure twice daily to meet caloric intake of 500 calories per day as well as nursing documentation upon admission that the patient is at risk for aspiration. There is no evidence that the plan of care includes problems, goals and interventions related to nutrition.

Upon patient record review, 1 of 15 (Patient #4) did not have evidence in the patient record that hospice aide assignments and duties are: • Assigned to a specific patient by a registered nurse that is a member of the interdisciplinary group • Written patient care instructions for a hospice aide must be prepared by a Registered Nurse who is responsible for the supervision of a hospice aide as specified under paragraph (h) of 418.76 • There is evidence in the patient record that the plan of care; indicate what tasks are to be done by the Aide and the frequency of these tasks. The use of “PRN” or “per patient choice”, for any task, whether personal care or non-personal care tasks, are not acceptable Patient 4:The aide plan of care developed on 6/18/23 included the task of dressing the patient. There is no evidence that the frequency for dressing the patient was included in the plan of care.

Upon patient client record review, 2 of 15 (Patient #2,#6) did not have evidence that all entries are legible, clear, complete, and appropriately authenticated and dated in accordance with the organizations policies and procedures and currently accepted standards of practice. Electronic signatures are acceptable as long the hospice is following appropriate safeguards to prevent unauthorized access to the patient records. Patient 2:On the Certification of Terminal Illness for benefit period 3 with certification dates of 9/3/23 through 11/1/23, the face to face is noted to have been completed on 8/30/23. However, per the visit note the face to face visit was completed on 8/27/23 with the signature associated with the clinician completing documentation of the visit dated 8/30/23. Patient 6:On the Certification of Terminal Illness for benefit period 5 with certification dates of 8/6/23 through 10/4/23, the face to face is noted to have been completed on 8/3/23. However, per the visit note the face to face visit was completed on 8/1/23 with the signature associated with the clinician completing documentation of the visit dated 8/3/23.